Cannabis and Physiotherapy: What you Need to Know

As of October 17th, 2018 marijuana will officially be legal in Canada, not only for medicinal purposes but also for recreational use. Many people turn to cannabis for pain management or symptom relief from conditions such as Multiple Sclerosis, Parkinson’s Disease, epilepsy, anxiety, depression, and chronic pain. Physiotherapists also work with many of these conditions, specializing in restoring function, movement, and helping patients return to a pain-free life. Therefore, this article will explore how these factors interact and what you need to know. I hope this post will help clarify how cannabis use may affect exercise and therapy, as well as your responsibilities surrounding the marijuana conversation.

First a Quick Lesson on Cannabis!

Marijuana1 is the part of the Cannabis plant that is used for its cannabinoids. There are two main cannabinoids: THC (tetrahydrocannabinol) and CBD (cannabidiol). While both provide therapeutic effects for different conditions, THC gives the psychoactive effects typically associated with marijuana smoking (think ‘Cheech and Chong’ or ‘Pineapple Express’). THC is only present if the plant is activated through decarboxylation2 – this is why it is heated in some manner by smoking it or cooking with it. THC and CBD both have specific doses and therapeutic ranges to have a beneficial effect on medical conditions (and less of the ‘high’ effects), and one type may help certain conditions more than others.1 For example, CBD is used to control epilepsy in children while others may use THC for chemotherapy-induced nausea relief. Some conditions may require a combination of both CBD and THC to gain therapeutic effects.

Is marijuana or cannabis the magic solution to many problems? I’ve seen many videos online of individuals using various cannabis products resulting in incredible results, from individuals with Parkinson’s no longer having tremors to children being cured of their seizures to managing symptoms from multiple sclerosis (MS) such as chronic pain and spasticity. But what does the science say? With all the buzz (excuse the pun) around marijuana’s beneficial effects, there is a lot of research that is on-going, so this is something to watch as higher-quality studies are conducted. Some conditions do have evidence that cannabis is beneficial with the appropriate type and dosage (spasticity relief in multiple sclerosis), but others have weaker evidence to date (fibromyalgia pain relief).3 Looking at one of the most popular medical databases, Dynamed, recent updates this September continue to show mainly “weak recommendations” for cannabis use.4 This means that evidence is insufficient with regards to the balance between benefits and harms, the biggest harm5 being the adverse effects of smoking on the lungs. It also indicates that there is still a fair amount of disagreement amongst clinicians as to its benefits. Aside from the stigma that can extend into the medical field, this can explain why marijuana is not prescribed as the first option for various conditions. With the imminent legalization of marijuana for recreational use in Canada, it will be interesting to see if and how this changes.

Some Things to Consider About Cannabis

#1: Even though physiotherapists learn about many medications and may have personal experience with the benefits that can be obtained from various medications, we cannot recommend you to take any specific one. This includes giving advice for taking any form of cannabis for your condition. When it comes to any medication (including marijuana), it is best to consult with your doctor or local pharmacist.

#2: If a clinician believes patients are under the influence of any drug (including cannabis) or alcohol leading them to be unsafe to participate in therapy, they will recommend rescheduling the appointment. Also, in accordance with the Physiotherapy Alberta guidelines (there are similar guidelines in other provinces) and the Traffic Safety Act, we are also obligated to inform the police if we believe a patient will be driving impaired (this also applies for alcohol).6Canadian Police will have the ability to conduct drug tests for cannabis, the psychoactive agent, using saliva instead of the breathalyzer used for alcohol. The MTL Blog linked here summarizes the driving fines if caught driving under the influence.

#3: As mentioned above in our quick lesson, marijuana can have various effects on how we move and function. Some of these effects can impact your cardiovascular function, your perception of pain, and your memory or attention (these are discussed in more detail below).7 Please inform your physiotherapist of all medications, vitamins and substances used so they can appropriately tailor your therapy and exercise program as required.

What to do as a Physiotherapist When Your Patient is Using Cannabis

#1: It’s as legal as drinking, smoking, Tylenol, and Big Macs with an extra-large side of fries! Do not be quick to judge but don’t be quick to gloss over this piece of information. It is important for us to take a thorough history and we should ensure our patients feel comfortable about sharing this information with us. By finding out why someone is using cannabis, we can offer solid education, appropriate therapy, and evidence-based resources to manage their condition and lead a healthy lifestyle.

#2: If your patient asks you for your opinion on marijuana use for their condition and if you think they are a candidate for it, you may not advise your patient to use marijuana. You may give your patient some guidance towards reputable sources of information and refer them to their doctor or pharmacist. As with any medication, you should help monitor your patient’s response to marijuana use concerning their symptom management.

#3: The body has many reactions to cannabis and thus may require you to modify how you deliver therapy, what may be appropriate, and what should be monitored.7 As there are many different dosages and variations, it is best to be cautious if you know your patient recently used marijuana or if they are a regular user. Cannabis is most often used for its nociceptive pain relief properties, which may lead your patient to have a blunted response to pain.7 As a result, some modalities8 which require intact sensation, such as electrical stim or heat, may be contraindicated, while others (such as pulsed ultrasound and NMES) may be used with precaution. Also, it can have an effect on short-term memory or cognition which may impact how your patients may retain educational tips or home exercise programs.7 It may also slow reaction times which may be noticeable if challenging your patient on certain exercises. Finally, the use of cannabis affects cardiovascular and respiratory function, leading to bronchodilation, increased heart rate and increased blood pressure.7 In addition to monitoring vitals, you may want to reconsider doing higher-intensity aerobic exercises if someone recently used cannabis products. Long-term, it may lead to opposite effects of decreased heart rate and blood pressure, as well as respiratory issues associated with smoking.

#4: If they appear impaired6, you should follow your policies and procedures that already exist for any impaired individual such as someone who is intoxicated or impacted by other prescription medications. This may mean altering your treatment or cancelling it. Also, if you suspect someone is driving while under the influence, by law you must notify the local authorities

Final Thoughts on Cannabis

If you are curious about using cannabis, I felt this introductory video by a chronic pain sufferer was quite informative and researched as she documents what she has done for pain relief followed by her experience with various cannabis products. This serves to highlight even more how one solution does not fit every problem and may give you some more insight into the variety of products that are available. If you have stigmas around marijuana use, I hope this will also serve to help you see past these stigmas and note how for some people, this may be one of their tools to finding relief and regaining control over their lives.

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